DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62493 (Rev. 06/09)
STATE OF WISCONSIN
Chapter 50, Wis. Stats. Page 1 of 2
REFERRAL FOR PRE-ADMISSION CONSULTATION
I. Information About the Facility (provided by the facility)
Name of Facility: Address: Contact Person: Telephone Number: E-mail Address:
II. Information About the Person Considering Admission (provided by the prospective resident or by the representative --indicated in Section III below --- on the behalf of the prospective resident)
Name Prospective Resident: Street Address: City: Telephone Number: State: Zip Code: E-mail Address: County: Date of Birth: / /
1. Have you been informed by facility staff of the cost for your care at this facility? Yes No
2. Do you have enough money to pay for the cost of your care at this facility for at least 6 months? Yes No Not Sure
3. Have you reviewed a copy of the brochure, "Considering Assisted Living or Nursing Home: What You Should Know," provided to you by facility staff? Yes 4. No
Would you like an opportunity to talk with someone from the Aging and Disability Resource Center or from the local human services department about long term care options; facilities and services available in your community; and / or Medicare, Medicaid, and other potential sources of financial assistance? (There are no charges for these services.) Yes No Not Sure
III. Information About the Representative (provided by the representative for the prospective resident, if appropriate)
Name Representative: Street Address: City: Telephone Number: State: Zip Code: E-mail Address: County: Relationship:
SIGNATURE Prospective Resident or Representative
Date Referral Sent
FOR FACILITY USE ONLY
Carefully read instructions on page 2 before completing and submitting this form.
F-62493 (Rev. 06/09)
Page 2 of 2
INSTRUCTIONS FOR REFERRAL FOR PRE-ADMISSION CONSULTATION
PROSPECTIVE RESIDENT: The information you provide will be used by the ADRC or county agency to track contacts with facilities in the area. It will not be shared. However, the ADRC or local human services department may contact you or your representative after receiving the referral.
I. Information About the Facility
This information is to be provided by the facility. Name of Facility and Type. Enter the name of the Community Based Residential Facility, Nursing Home, or Residential Care Apartment Complex that is making the referral to the Aging and Disability Resource Center or human services department (County Waiver Program). Indicate the type of facility by checking the appropriate checkbox. Street Address. Enter the complete address, including the city, state, and zip code of the facility that is completing the Referral for Pre-Admission / Consultation. Contact Person. Enter the name of the facility staff contact person (e.g., the staff person completing the form or another appropriate staff person, such as the admissions coordinator). Telephone Number. Enter the telephone number of the facility staff contact person. E-mail Address. Enter the e-mail address of the facility staff contact person.
II. Information About the Person Considering Admission (Prospective Resident)
This information is to be provided by the prospective resident. If the prospective resident is unable to complete this section, the representative indicated in Section III should complete this section for the prospective resident. Name Prospective Resident. Enter your complete name on the line provided. Date of Birth. Enter your date of birth (Month / Day / Year). Street Address, City, State, Zip Code. Enter your complete address on the lines provided. County of Residence. Enter the name of the county in which you reside. Telephone Number. Enter your telephone number. E-mail Address. Enter your e-mail address, if available. Questions 1 4. Check the appropriate box --- "Yes," "No," or "Not Sure" --- for questions 1 through 4. If you have questions regarding the information, please ask for assistance from staff at the facility.
III. Information About the Representative
This information is to be provided by the representative for the prospective resident, if appropriate. Name Representative. If you have contacted the facility on behalf of the prospective resident, enter your full name. Relationship. Indicate the type of relationship that exists between the prospective resident and yourself (spouse, son, daughter, niece, etc.) Street Address, City, State, Zip Code. Enter your complete address on the lines provided. County of Residence. Enter the name of the county in which you reside. Telephone Number. Enter your telephone number. E-mail Address. Enter your e-mail address, if available. Signature Prospective Resident or Representative / Date Signed. The prospective resident or their representative should sign on the line provided and enter the date that the form is signed. FOR FACILITY USE ONLY · If the prospective resident or their representative refuses to complete the form, (1) fill in the name, address, and telephone number of the prospective resident in Section II; (2) indicate on the "Signature" line that he/she declined to sign the form; (3) provide the date; and (4) submit the referral form as directed below. CBRFs / RCACs: Submit a completed copy of this form to the appropriate Aging and Disability Resource Center or to the human services department in the county of residence no later than the close of the next business day after facility staff first provides written information to the prospective resident or representative. Nursing Homes: Submit a completed copy of this form to the appropriate Aging and Disability Resource Center no later than the close of the next business day after the facility first provides an assessment of the person's needs for nursing or residential services or at the time that it accepts an application for admission from the person. · Enter the date that the referral is sent to the ADRC / human services department. Keep the original referral form in the prospective resident's file.